Surgical therapy for urinary incontinence has made tremendous advances over the last decade. A relatively new minimally invasive technique to treat stress urinary incontinence is gaining popularity among urologists, the self fixating mid-urethral slings. These slings can be placed using a variety of approaches, tailored to meet the needs of the patient, and have a high success rate. The technique can be performed in 30 minutes and requires small vaginal and suprapubic or thigh crease incisions. Patients can return to full activity within two weeks. Another approach to managing stress incontinence is with bulking agents which are injected near the urethral sphincter to increase coaptation. This procedure is very low risk and can be performed in the office with local anesthesia.

In the past, urge incontinence could only be treated with medications or complex urinary diversions. Recently, urologists have realized the potential applications of Botulinium A toxin in the lower urinary tract. This minimally invasive therapy is performed in the office and has been shown to be effective in the management of idiopathic and neuropathic bladder overactivity, detrusor sphincter dysynergia, and urinary retention.

Sacral neuromodulation has been another new breakthrough therapy for patients with refractory conditions of the lower urinary tract. This therapy uses an implantable neurostimulator and lead to generate electrical pulses to stimulate the sacral nerves which influence behavior of the bladder, sphincter, and pelvic floor. It has proven to provide safe and effective relief of urinary urge incontinence, non-obstructive urinary retention, and urgency-frequency syndrome. The procedure is performed in 2 stages. In the first stage, a lead is placed near the sacral nerve root and connected to a temporary stimulator. If the stimulator provides successful relief of symptoms, the permanent neurostimulator is placed in a subcutaneous pocket in the upper buttock.

Surgery for Pelvic Organ Prolapse

The goal of repair of pelvic organ prolapse is to restore normal function and anatomy of the pelvic floor and its organs. Repair of the defects that allow the pelvic organs to herniate can be accomplished using several different surgical techniques and approaches including laparoscopy and robotics. When compared to open, laparoscopic abdominosacrocolpexy has shown excellent results, with decreased lengths of hospital stay and postoperative pain and a quicker return to preoperative levels of activity.

Traditional repairs, either through a vaginal or abdominal approach, involve reapproximation of the patient’s own tissue. More repairs are now being accomplished with synthetic mesh and other biologic materials to augment and increase the durability of the repair. The newest minimally invasive approach, which has been used in Europe for the past 2 years and is now available in the U.S, is the tension free vaginal mesh. Soft prolene mesh is placed between arcus tendineus and sacrospinal ligaments using needle introducers through the obturator foramen. Short term data indicate high success rates and low complication rates.

Male Stress Incontinence

Male stress incontinence is caused by weakened urethral sphincter muscles. Pelvic trauma and pelvic surgery such as prostate surgery are the principal causes of male stress incontinence. For the past 2 decades, the artificial urinary sphincter has been the gold standard of treatment. It provides an excellent cure rate, even for severe incontinence, but can also be complicated by infection and erosion. The male sling is a new minimally invasive alternative to the artificial urinary sphincter. It is used to treat mild to moderate stress incontinence. It is performed with a two-inch incision. A sling is formed by taking a piece of synthetic material and using it to compress the urethral sphincter, thus preventing leakage of urine during stress maneuvers. The operation commonly takes less than an hour and can be performed in the outpatient setting.